Annotation of a wavefront with evaluation of the ratio of a bipolar derivative to a local unipolar minimum derivative

ABSTRACT

A method, including receiving a bipolar ECG signal from a location in the heart from the pair of electrodes, receiving a unipolar ECG signal from the location in the heart from a selected one electrode of the pair of electrodes, computing a local unipolar minimum derivative of the unipolar signal at a plurality of times of occurrences of the local unipolar minimum derivative, computing a bipolar derivative of the bipolar signal, evaluating a ratio of the bipolar derivative to the local unipolar minimum derivative at the plurality of times of occurrences of the local unipolar minimum derivative, annotating each time of occurrence as a time of activation of the myocardium at the location in the heart when the ratio is greater than a preset threshold value, merging two annotations that arise from a single occurrence as a single annotation, evaluating features of the annotations and assigning a confidence level to each feature, eliminating annotations that have a confidence level below a threshold and generating a local activation time map using the remaining annotations.

CROSS-REFERENCE TO RELATED APPLICATION

This application is a continuation of application U.S. Ser. No. 15/646,373 now U.S. Pat. No. 10,383,534, filed on Jul. 11, 2017 and claims the benefit of U.S. Provisional Patent Application 62/373,458, filed Aug. 11, 2016, which is incorporated herein by reference. This application is related to application U.S. Ser. No. 15/646,393 titled “Classifying ECG Signals,” filed on Jul. 11, 2017.

FIELD OF THE INVENTION

This invention relates generally to electrocardiograph (ECG) signals, and specifically to a method for annotating the signals.

BACKGROUND OF THE INVENTION

Mapping and imaging of the electrical signals in the heart is typically based on combining local activation time (LAT), as indicated by a catheter's ECG signals, with the spatial position of the signals. Such a method is used in the CARTO® 3 System, produced by Biosense Webster of Diamond Bar, Ca.

Existing activity measurement algorithms are based on processing of bipolar signals which are inherently immune to far field interference. Historically, LAT is determined by the time difference between the reference annotation and the earliest activity in the bipolar signal in the mapping catheter channels. However, determining earliest activations in bipolar signals presents an ambiguity in LAT measurements since the earliest activation is a composition of the approaching fields from the two unipolar signals and does not necessarily correspond to the onset of the activity wave.

Documents incorporated by reference in the present patent application are to be considered an integral part of the application except that, to the extent that any terms are defined in these incorporated documents in a manner that conflicts with definitions made explicitly or implicitly in the present specification, only the definitions in the present specification should be considered.

SUMMARY OF THE INVENTION

An embodiment of the present invention provides a method, including: receiving a bipolar ECG signal from a location in the heart from the pair of electrodes;

receiving a unipolar ECG signal from the location in the heart from a selected one electrode of the pair of electrodes;

computing a local unipolar minimum derivative of the unipolar signal at a plurality of times of occurrences of the local unipolar minimum derivative;

computing a bipolar derivative of the bipolar signal;

evaluating a ratio of the bipolar derivative to the local unipolar minimum derivative at the plurality of times of occurrences of the local unipolar minimum derivative;

annotating each time of occurrence as a time of activation of the myocardium at the location in the heart when the ratio is greater than a preset threshold value;

merging two annotations that arise from a single occurrence as a single annotation;

evaluating features of the annotations and assigning a confidence level to each feature;

eliminating annotations that have a confidence level below a threshold; and

generating a local activation time map using the remaining annotations.

There is further provided, according to an embodiment of the present invention, apparatus, including:

a pair of electrodes configured to be placed in proximity to a myocardium of a human subject; and

a processor configured to:

receiving a bipolar ECG signal from a location in the heart from the pair of electrodes;

receiving a unipolar ECG signal from the location in the heart from a selected one electrode of the pair of electrodes;

computing a local unipolar minimum derivative of the unipolar signal at a plurality of times of occurrences of the local unipolar minimum derivative;

computing a bipolar derivative of the bipolar signal;

evaluating a ratio of the bipolar derivative to the local unipolar minimum derivative at the plurality of times of occurrences of the local unipolar minimum derivative;

annotating each time of occurrence as a time of activation of the myocardium at the location in the heart when the ratio is greater than a preset threshold value;

merging two annotations that arise from a single occurrence as a single annotation;

evaluating features of the annotations and assigning a confidence level to each feature;

eliminating annotations that have a confidence level below a threshold; and

generating a local activation time map using the remaining annotations.

The present disclosure will be more fully understood from the following detailed description of the embodiments thereof, taken together with the drawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a schematic block diagram of an algorithm, according to an embodiment of the present invention;

FIG. 2 is an example of activity as measured by a bipolar signal and a unipolar positive electrode signal, according to an embodiment of the present invention;

FIG. 3 is a graph illustrating baseline wander removal, according to an embodiment of the present invention;

FIG. 4 is a block diagram of a baseline wander removal system, according to an embodiment of the present invention;

FIG. 5 is a graph of two Gaussian filters, according to an embodiment of the present invention;

FIG. 6 is a schematic block diagram of an Annotation Detector block according to an embodiment of the present invention;

FIG. 7 is a graph of unipolar and bipolar signals, and their derivatives, according to an embodiment of the present invention;

FIG. 8 shows graphs illustrating a first rejection phase of an annotation algorithm, according to an embodiment of the present invention;

FIG. 9 shows graphs illustrating local and far field candidate annotations, according to an embodiment of the present invention;

FIG. 10 is a graph illustrating merging of candidate annotations, and how rejection criteria are used, according to an embodiment of the present invention;

FIG. 11 is a graph of a unipolar derivative fuzzy function, according to an embodiment of the present invention;

FIG. 12 is a graph illustrating unipolar signal segmentation, according to an embodiment of the present invention;

FIG. 13 is a graph of a unipolar duration fuzzy function, according to an embodiment of the present invention;

FIG. 14 is a graph of a unipolar amplitude fuzzy function, according to an embodiment of the present invention;

FIG. 15 is a graph of a unipolar duration to amplitude ratio fuzzy function, according to an embodiment of the present invention;

FIG. 16 is a graph of a bipolar amplitude fuzzy function, according to an embodiment of the present invention; and

FIG. 17 is a schematic illustration of an invasive medical procedure using an apparatus, according to an embodiment of the present invention.

DETAILED DESCRIPTION OF EMBODIMENTS Overview

Unlike bipolar signals the onset of the activity in a unipolar signal is clearly marked by a sharp downward deflection in the signal, but unlike bipolar signals the unipolar is sensitive to far field activations.

Embodiments of the present invention use a wavefront annotation algorithm which acts to combine the properties of the two types of ECG signals—a bipolar signal together with one of its associated unipolar signals—to generate accurate signal annotations. The inventors have verified that the algorithm provides accurate annotations which are immune to far field interferences.

The wavefront annotation algorithm provides automatic and reliable detection of annotation points that enable acquisition and annotation of numerous LAT points in a relatively short time.

An embodiment of the present invention comprises receiving a bipolar signal from a pair of electrodes in proximity to a myocardium of a human subject. A unipolar signal is also received from a selected one of the pair of electrodes, and a local unipolar minimum derivative of the unipolar signal is computed. A time of occurrence of the unipolar minimum derivative is also computed. A bipolar derivative of the bipolar signal is computed, and a ratio of the bipolar derivative to the local unipolar minimum derivative is evaluated.

When the ratio is greater than a preset threshold ratio value, the time of occurrence (of the unipolar minimum derivative) is identified as a time of activation of the myocardium.

DESCRIPTION OF EMBODIMENTS

FIG. 1 is a schematic block diagram of a wavefront annotation algorithm, according to an embodiment of the present invention. The algorithm inputs consist of a single bipolar signal and one of its unipolar signals, which are typically provided to a processor 20 operating the algorithm, following a low pass filter with a cut-off of 500 Hz and a power rejection filter. More detail of the operation of processor 20 is provided with reference to FIG. 17 below. The polarity of the unipolar signal is assumed to be known (i.e. it is derived from either a positive or a negative electrode). The processor may be a stand-alone processor, and/or a general purpose processor that is typically operating a computer. The algorithm comprises a number of stages, summarized here.

A pre-processing stage 22 includes removal of baseline wander, low pass filtering and any order of differentiation. The removal of baseline wander includes removal of an additive low frequency signal that is an artifact and originates from various reasons such as mechanical catheter movement or respiration. This low frequency signal can alter the estimated derivative of the signals and therefore is typically removed.

A feature extraction stage 24 uses the post-processed signals and extracts features for every candidate annotation.

A first annotation detector stage 26 performs eliminations of candidate annotations based on a subset of features.

Next, in a pair elimination stage 28 candidate annotations that pass the required feature threshold, but are insignificant relative to another very close activation may be discarded.

Finally, in a second annotation detector stage 30 a score is given to each candidate annotation based on its feature values. Only candidate annotations that surpass the score thresholds are considered as valid annotations, and the timing and features of these are used by the processor in further operations of the processor, such as generating a map of the candidate annotations.

The elements of the algorithm are described in more detail below.

The core of the algorithm relies on three basic observations:

-   -   Unipolar activity is marked by a sharp downward deflection in         the signal amplitude. These deflections can be easily identified         as local minima in the activity velocity signal (i.e. the         derivative of the unipolar signal). However, not all local         minima are indicative for activity; some are results of noise or         far field activity. Therefore, the purpose of the algorithm is         to distinguish between local minima in the velocity signal that         are correlated with local real activations and those that are         not. This is possible using the next observation.     -   Far field activations affect the potential of the unipolar pair         almost identically. Therefore, their bipolar counterpart has         only residual activity during far field activation. This is not         the case during local activity measurements when one of the         electrodes is in proximity with the activation and the other is         relatively far (even a few mm is sufficient). In this case the         bipolar signal will also exhibit slope change concurrent with         the slope change in the unipolar signal (see FIG. 2 and its         description below). Using this phenomenon it is possible to         distinguish between unipolar sharp deflections arising from near         field activations and those arising from far field activations.     -   Combining multiple features of candidate annotations provides a         method for making a more robust annotation detection. For         example, bipolar amplitude change as a result of local         activation may be used as a feature. However, sometimes a far         field activation may have a bipolar component (for example when         mapping inferior atria near the ventricle valve). Therefore,         decision making that is based solely on the bipolar amplitude         may fail. However, if additional features of the signals are         used the decision making may be more robust. One such feature         can be the unipolar amplitude around the activation (FIG. 2).

FIG. 2 is an example of activity as measured by the bipolar signal and the unipolar positive electrode signal, according to an embodiment of the present invention. A graph 40 shows the bipolar signal; a graph 44 shows the unipolar signal. The sharp downward deflection on the left, in a region “A”, is a near field activity which is concurrent in the unipolar and the bipolar signals. As shown in a region “B” during far field ventricular activation the unipolar signal changes, however, the bipolar activity is negligible. Embodiments of the present invention use multiple features of the signal similar to those exemplified above to assist in separating between local and far field activations. For example, in region A the unipolar amplitude and its rate are similar to the bipolar signal, while in region B the unipolar signal amplitude is much larger and its rate is much faster than the bipolar signal.

The following description describes the elements of the algorithm illustrated in FIG. 1.

Pre-Processing and Feature Extraction Stages 22 and 24 (FIG. 1)

The purpose of these pre-processing and feature extraction stages is to remove and attenuate interferences in the unipolar and bipolar signals while maintaining and emphasizing those features of the signal that are used in subsequent stages. While for simplicity the actions described herein are assumed to occur in stages 22 and 24, it will be understood that at least some of these actions may occur in other stages of the algorithm. A characteristic that we want to retain is the morphology of activations, since it reflects slope changes. Characteristics that are typically discarded are the baseline-wander that acts as an additive signal that can corrupt the slope measurements and also high frequency noise. Stages 22 and 24 are divided into four sub-stages:

1. Unipolar Pre-Processing Sub-Stage

The Unipolar pre-processing stage consists of applying the following steps in series:

-   -   1. Baseline estimation and subtraction (using a median filter+a         low pass filter (LPF)) at 1 KHz     -   2. Upsampling to 8 KHz (Sample and hold or other upsampling         technique by factor of 8)     -   3. First Smoothing Filter—LPF FIR (−6 db @ 155 Hz, 145 Taps).         The filter is a convolution of a 65 taps Equiripple filter of         500 Hz and Gaussian 10 ms window.     -   4. Second Smoothing Filter—The filter used is an antialiasing         LPF of the system, typically a 500 Hz low pass filter.     -   5. Derivative

The derivative of step 5 is used as an input to a unipolar annotation detector-(Phase I) in first annotation detector stage 26 (FIG. 1). The additional filtered signal output of step 4 is used for feature extraction stage 24 of the algorithm.

2. Bipolar Pre-Processing Sub-Stage

The bipolar pre-processing stage consists of applying the following steps in series:

-   -   1. Baseline estimation and subtraction (median filter+LPF) at 1         KHz     -   2. Upsampling to 8 KHz (Sample and hold by factor of 8)     -   3. Smoothing—LPF FIR (−6 db @310 Hz, 113 Taps). The filter is a         convolution of a 65 taps Equiripple filter of 500 Hz and         Gaussian 6 ms window.     -   4. Derivative

The final output of the bipolar preprocessing stage (the bipolar derivative) is used as an input to the unipolar annotation detector-(Phase I) referred to above (FIG. 1).

3. Baseline Wander Estimation Sub-Stage

Intra-cardiac (IC) signals may contain additive baseline wander signals arising from movement of the catheter, movement of the subject and respiration that changes the interface with the tissue (see FIG. 3 and its description below). These motion artifacts contain mostly low frequency components. However, the near field activity signal may also contain significant energy in these spectral bands. Therefore the conventional approach of removal by high pass IIR or FIR filter is problematic and can cause distortion and morphology changes to the IC signals. Consequently, the selected approach that we use is based on estimation of the baseline wander (FIG. 3) and its subtraction from the signal.

FIG. 3 is a graph illustrating baseline wander removal, according to an embodiment of the present invention. A unipolar signal 50 is originally contaminated by a low frequency artifact, contributing to the baseline wander. The purpose of the baseline estimation is to calculate the baseline which is then subtracted from the signal. In the figure a calculated baseline 54 has been overlaid on the unipolar signal. Baseline wander rejection is important since baseline wander can add noise to the estimate of the unipolar derivatives, and thus may affect the annotation detection.

The estimation of the baseline wander, and its subtraction from the original, is accomplished by removal of the near field activity using a series of two filters as is illustrated in FIG. 4.

FIG. 4 is a block diagram of a baseline wander removal system, according to an embodiment of the present invention. A median filter 60, typically having a window of 60 ms, is designed to remove the activities from the raw signal while an LPF 64, which in one embodiment is an 89 taps FIR Hanning filter with a typical cut-off of approximately 10 Hz, is designed to smooth out edges resulting from the median filter. Finally the baseline estimate is subtracted from the raw signal, by a process of negation 68 then summation 72, resulting in a signal free of baseline wander.

4. Smoothed Derivative Sub-Stage

FIG. 5 is a graph of two Gaussian filters, according to an embodiment of the present invention. The detection of sharp deflection points in the signal is based on the velocity of the signal, therefore a derivative approach is used. However, derivative functions act as a high pass filter, thus enhancing high frequency noise. Therefore, we use a smoothing function to decrease the noise in the derivative estimation. The smoothing function that we use are normalized zero mean Gaussian functions, comprising a unipolar Gaussian function 80 and a bipolar Gaussian function 84, illustrated in FIG. 5. These unipolar and bipolar Gaussian filters have 90% of the energy in time windows of ±2 ms and ±1 ms respectively. Thus activations or approaching far fields at distances larger than these values are virtually ignored and do not affect the derivative value.

Annotation Detector-I Stage 26 (FIG. 1)

Reference is now made to FIGS. 6-9. FIG. 6 is a schematic block diagram of Annotation Detector-I stage 26; FIG. 7 is a graph of unipolar and bipolar signals, and their derivatives; FIG. 8 has graphs illustrating a first rejection phase of the annotation algorithm; and FIG. 9 has graphs illustrating local and far field candidate annotations, according to embodiments of the present invention.

Referring to FIG. 6, Table I below gives parameters used in the detector, and corresponding acronyms in the block diagram.

TABLE I Parameter Acronym Smoothed Unipolar Derivative S-Uni Smoothed Unipolar Derivative Threshold Th-Uni Smoothed Bipolar Derivative S-Bip Smoothed Bipolar Derivative Threshold Th-Bip $\frac{S\text{-}{Bip}}{S\text{-}{Uni}}$ R The minimal ratio that R should exceed in order to be a valid Th-Ratio annotation at the output of annotation detector-I

FIG. 7 shows an example of a bipolar slope of zero around a unipolar annotation. The graphs show a unipolar distal signal 100, its derivative 102, its local activation (A) as well as a bipolar signal 104, and its derivative 106. Notice that at the unipolar deflection point (A) the bipolar derivative is almost zero and it is not indicative of the large change in bipolar amplitude.

FIG. 8 has graphs illustrating a first rejection stage of the annotation algorithm of FIG. 1. A top graph 110 shows the unipolar signal and a bottom graph 114 shows its smoothed derivative. Black dots 118 are minima values in the derivative signal below a threshold value and will be further considered as possible annotation points while grey dots 122 mark minima value above the threshold that will be rejected.

FIG. 9 illustrates separation between local (A) and far field (B) candidate annotations using the bipolar and unipolar derivative ratio feature described herein. The figure shows unipolar 130 and bipolar 132 signals, and unipolar 136 and bipolar 138 derivatives. In local activation, unipolar derivative changes are accompanied by a bipolar derivative change as illustrated by a 2 ms activity window 140. However, this is not the case in the far field derived deflection (B), as illustrated by window 144, thus the ratio between the change in the bipolar and unipolar slope for the far field case will be below the required ratio threshold.

Returning to FIG. 6, the inputs for the annotation detector-I block are the relevant unipolar signal derivative under test, its polarity and its smoothed bipolar derivative. The outputs of the block are the annotation indexes and their slope value (the unipolar derivative value at the annotation index). The slope value acts as the score of the annotation.

In an embodiment of the invention the deflection points in the downslopes of the unipolar signal are detected, in blocks 90 and 92, by finding the minima points below a threshold (typically −0.01 mv/ms), see also FIG. 8. Activities typically satisfy this condition in addition to two others:

-   -   1. The value of the bipolar smoothed derivative signal (S-BIP)         in a time window around the unipolar deflection points         (typically ±2 ms) should exceed in a negative manner, a         threshold TH-BIP. Thus, S-BIP<TH-BIP. In one embodiment TH-BIP         is typically about 0.008 mv/ms.     -   2. The ratio between this bipolar smoothed derivative value and         the unipolar smoothed derivative slope value should be higher         than Th-Ratio, typically about 0.2.     -   #1 and #2 are evaluated in blocks 94 and 96, and in a decision         98.

Referring to FIG. 6, the bipolar derivative value (S-bip) is computed differently for positive and negative electrodes. In a disclosed embodiment, for a positive electrode it is the minimal value within a 2 ms time window, and for a negative electrode it is the negative value of the maximal value within that time window. The reason for using a time window and not the derivative at the annotation point is that in certain pathologies and/or orientations (of the catheter and the wave propagation direction) the bipolar signal at a given point can be small or even zero since the time delay of activities between unipolar activations can cancel out (FIG. 7). The value is calculated differently for positive and negative electrodes since the tip activity at the positive electrode is registered as a downslope in the bipolar signal, while activity at the negative electrode is registered as an upslope in the bipolar signal.

The ratio between the unipolar and the bipolar derivatives may also be used as a classification criterion since this criterion can distinguish between near field and far field activity. In near field activity at least some of the downslope activity is typically represented in the bipolar signal, while in far field cases the bipolar signal may only have residual activity.

Pair Elimination Stage 28 (FIG. 1)

The pair elimination stage of the algorithm is responsible for merging two annotations that arise from a single activity. This split phenomena can occur when for some reason the downward slope of a near field activity contains a momentary upslope, either from activity recorded in the other electrode or from far field activity that influences one electrode more than the other. The momentary upslope will cause two minima in the derivative of the signal, and if these are strong enough they result in two annotations. In order to exclude these cases we evaluate the change in the signal due to the upslope.

All annotation pairs in the same unipolar signal that are not too far apart (typically less than 50 ms) are analyzed for a split. The segment between the two candidate annotations in the unipolar derivative signal is analyzed for upsloping. When the upsloping amplitude is considered significant the two annotations are maintained. If not, the annotation with a smaller downslope is discarded.

FIG. 10 is a graph 150 illustrating merging of candidate annotations, and how rejection criteria are used, according to an embodiment of the present invention. The graph shows a unipolar derivative signal and two possible annotations (circles, marked A[i] and A[i+1]).

The purpose of pair elimination block 38 is to decide whether the upsloping amplitude change (marked with a vertical double-headed arrow) between the smallest derivative amplitude and the peak P between the two possible annotations is significant or not. If the change is considered significant both annotations are maintained, otherwise the weaker activation—A[i] is discarded.

Thus, for an annotation A[i] to be discarded the relative change to the peak amplitude (P) between any adjacent candidates annotation with a stronger slope within the 50 ms time windows A[i+1] is considered. If the peak is significantly higher this point will not be rejected. In mathematical terms, in one embodiment, if the value of (P−A[i])/(0.02−A[i]) is lower than 0.5 the annotation A[i] is discarded. I.e., annotation A[i] is rejected if one or more annotations in the 50 ms time window follow the above rule.

Annotation Detector II Stage 30 (FIG. 1)

The candidate annotations that passed the earlier phases are revaluated in this block using additional features and metrics. Only annotations that pass this block and that also pass a user bipolar voltage controlled threshold are considered valid annotations. For each annotation multiple features are computed. Each feature value is given a fuzzy score ranging from zero to one, corresponding to a confidence value for the feature. Finally, all scores are combined together and their value is tested against a global score threshold. Those annotations that pass the global score threshold, i.e., that have a high confidence value, are considered valid annotations and those that do not, i.e., that have a low confidence value, are rejected.

The fuzzy functions described herein are examples of such functions that are used in one embodiment of the present invention. However, other such fuzzy functions or other probabilistic terms/functions will be apparent to those having ordinary skill in the art, and all such functions are assumed to be included within the scope of the present invention. In addition, for a specific requirement multiple fuzzy scores may be used (for example—fuzzy functions that highlight strong or small bipolar signals etc. . . . )

All fuzzy functions are bounded between 0 and 1.

The features that the block uses are:

-   -   1. The unipolar derivative value     -   2. The duration, s₂, of the unipolar slope     -   3. The amplitude of the unipolar slope at that time window, s₂     -   4. The ratio between the above duration and amplitude     -   5. The bipolar signal amplitude in the time window—s₂

The five features are explained below.

1. Unipolar Derivative

FIG. 11 is a graph 160 of a unipolar derivative fuzzy function, according to an embodiment of the present invention. The graph provides a score f(s₁) assigned to the derivative, where the derivative value is herein termed s₁. As shown in the graph, values of the derivative below −0.07 receive a score of 1, and values larger than −0.07 decrease linearly such that a 0.5 score is reached at a slope of −0.018. Derivative values smaller than −0.01 receive a score of zero.

The unipolar derivative s₁ is used in both detector stages, but unlike the first stage where it has a dichotomy threshold of 0.01 my/ms, here its value is used to provide the score f(s₁). The higher the score the more probable that this is a valid annotation according to this feature alone.

2. Unipolar Activity Segmentation and Duration

FIG. 12 shows graphs illustrating unipolar signal segmentation, according to an embodiment of the present invention. The segmentation is described further below. A unipolar signal 170 and its derivative 174 are illustrated around a candidate annotation time index 176 (black dot). A dotted horizontal line 180 representing a threshold marks a search segment (typically approximately ±25 ms) in both directions. In one embodiment the segment value is defined as 20% of the absolute maximum unipolar derivative value at the annotation point. Segments A, B mark the time intervals within the search window where the signal derivative is below the threshold. A final segment in this example can be either segment A or, if certain conditions (described hereinbelow) are met, it can be the joint segment starting from onset of A to the end of B.

A feature that we derive from the unipolar signal is the duration s₂ of the downslope segment around the candidate annotation. The aim is to detect the unipolar downslope from its initial descent until it starts to upslope. The motivation is to inspect features of the signals in that segment, such as properties of duration, amplitude, and their relationship, and to use them as a basis for a classifier. The inventors considered several methods for this task, all of which worked well for the obvious cases of a single slope, but the method described herein was selected since it works well on complicated cases having slope trend changes and local peaks within the slope segment.

Referring to FIG. 12, the segmentation is based on analyzing the unipolar derivative via the following steps:

-   -   1. A 50 ms segment of unipolar signal derivative 174 centered on         the candidate annotation time index 176 is considered as the         maximum span on threshold line 180 for which the segment can be         defined. In FIG. 12 the span is between end points 182 and 186         of line 180. We assume that the unipolar signal down slope         segment is bounded in this 50 ms time window. If the segment is         larger than this it is force-bounded to this 50 ms interval.     -   2. The derivative segment amplitude is compared against a         constant threshold. The threshold in the embodiment described         herein is assumed to be 20% of the unipolar derivative value at         the candidate annotation time. Segments on line 180 that are         below that value are marked in FIG. 12 as two segments A and B.     -   3. The next step is to compute the segment bounds and to sum the         area under the derivative at each sub-segment separately,         corresponding to summing the absolute value of the signal in         those segments.     -   4. Segments merge—Based on the segments interspacing and their         area a decision is taken whether the final segment should         contain the main segment (A) or additional segments (B). In one         embodiment, in order for segments to join adjacent endpoints         must be 1 ms or less from each other and the additional         segment (B) should have an area less than 30% of the main         segment, so that the signal delta for B should be less than 30%         of the signal delta for A.

The duration determined from the above steps, herein termed s₂, is then assigned a score f(s₂) using the fuzzy function described below with reference to FIG. 13.

FIG. 13 is a graph 190 of a unipolar duration fuzzy function, according to an embodiment of the present invention. Very short slopes of less than 2 ms are unlikely to originate from real activation; very long activations are probably far field events. In addition, the unipolar duration for local valid activation cannot be too short and cannot be too long. The above observations are encapsulated in the fuzzy function of FIG. 13, which provides the score f(s₂). The function points 192, 194 are: {2,0.5}.{19,0.5} and the slopes are 0.5 and −0.5 respectively.

3. Unipolar Amplitude

FIG. 14 is a graph 200 of a unipolar amplitude fuzzy function, according to an embodiment of the present invention. The unipolar amplitude is the amplitude of the unipolar signal (herein termed s₃) in the detected activity segment (peak-to-peak) duration s₂. In one embodiment the fuzzy function slope intersects points 202, 204: {0.1,0.5},{0.42,1}. The score derived from the fuzzy function, f(s₃), is high the higher the amplitude of the signal. I.e., for high scores, and high amplitudes, the more likely it is that the signal originates from a local activation, unless the far field signals have a large amplitude.

4. Unipolar Duration to Amplitude Ratio

FIG. 15 is a graph 210 of a unipolar duration to amplitude ratio fuzzy function, according to an embodiment of the present invention. The unipolar duration to amplitude ratio excludes high ratio values since the longer the activity and the smaller the amplitude, the more likely that this is a false annotation. In one embodiment the equation of the fuzzy function line is f(s ₄)=−0.0184·s ₄+1.283  (1)

where s₄ is the duration to amplitude ratio, and

f(s₄) is the score assigned to the ratio.

5. Bipolar Amplitude

FIG. 16 is a graph 220 of a bipolar amplitude fuzzy function, according to an embodiment of the present invention. The bipolar amplitude within the unipolar activity segment (peak-to-peak), s₂, is also used for scoring the likelihood of the candidate annotations. The higher the value, the more likely that this is a true activation.

An equation for the fuzzy function is: f(s ₅)=25·s ₅, 0≤s ₅≤0.04; f(s ₅)=1, s ₅>0.04  (2)

where s₅ is the bipolar amplitude, and

f(s₅) is the score assigned to the amplitude.

The amplitude is calculated on the baseline rejected bipolar smoothed signal after low pass of Gaussian and anti-aliasing filter.

6. Final Score

As described above, each feature receives a score and the scores are used together in generating a global score. The idea is that features can support one another in inclusion or exclusion of an annotation. In one embodiment the score method which we used is defined as follows: GS=⁵√{square root over (Π₁ ⁵ f(s _(i)))}  (3)

where GS is the global score.

The value of GS should pass a specific threshold, for example 0.8, for the annotation to be considered as valid.

It will be apparent to those skilled in the art that global scores, different from those exemplified above but having an equivalent outcome, can be used in embodiments of the present invention. Such global scores can include substantially any combination of weighted average of individual scores, and/or dot products of individual scores. Such global scores can also include a composition of scores based on a subset of fuzzy features. The scope of the present invention includes all such global scores.

Bipolar Amplitude Filtering

In some embodiments a final stage of the algorithm is designed to provide the user the ability to eliminate annotations that were detected if they have a low bipolar amplitude. The required amplitude threshold is controlled by the user. The bipolar amplitude filtering compares the bipolar amplitude of each annotation that surpassed the post processing stage with a threshold. Only annotations having a bipolar amplitude that exceeds the threshold are passed to the system. (If a user desires to skip this stage she/he may set the threshold to zero, thus eliminating the rule of this stage.)

The bipolar amplitude of each annotation is defined by measuring the peak-to-peak amplitude, baseline removed, 1 KHz bipolar signal in a 14 ms window centered around the annotation time (maximum unipolar velocity point). In one embodiment a system default value of bipolar amplitude threshold is set to 30 micro Volts.

This bipolar amplitude is different from the fuzzy controlled bipolar amplitude (described above), since this bipolar amplitude is determined on a fixed interval. The fuzzy classifier uses a dynamic segment of the unipolar activation and therefore in some embodiments the dynamic segment may be more meaningful as a classifier. In addition this classifier is used as a dichotomic user controlled threshold.

Algorithm Final Output

All annotations that pass the fuzzy score and the bipolar user controlled bipolar amplitude are considered valid annotations that may be used by the processor.

In one embodiment each annotation should have the following features:

-   -   1. The annotation time index     -   2. The unipolar and bipolar derivative value     -   3. The fuzzy score     -   4. The unipolar detected downslope segment duration     -   5. The unipolar amplitude within that segment     -   6. The bipolar amplitude within that segment     -   7. The bipolar amplitude for the user controlled value

In addition trace files may be provided, to include

1. The specific fuzzy score for each of the features

2. The unipolar segment start and end time index

FIG. 17 is a schematic illustration of an invasive medical procedure using an apparatus 400, according to an embodiment of the present invention. The procedure is performed by a medical professional 402, and, by way of example, the procedure in the description hereinbelow is assumed to comprise acquisition of ECG signals from a heart 404 of a human patient 406.

In order to acquire the signals, professional 402 inserts a probe 408 into a sheath 410 that has been pre-positioned in a lumen of the patient. Sheath 410 is positioned so that a distal end 412 of the probe may enter the heart of the patient, after exiting a distal end 414 of the sheath, and contact tissue of the heart.

Probe 408 may comprise any type of catheter that can be inserted into the heart of the patient, and that can be tracked, typically using a magnetic tracking system and/or an impedance measuring system. For example, probe 408 may comprise a lasso catheter, a shaft-like catheter, or a pentaRay catheter, produced by Biosense Webster of Diamond Bar, Calif., or catheters generally similar to these catheters. Biosense Webster also produces a magnetic tracking system and an impedance measuring system that may be used in embodiments of the present invention.

Probe 408 comprises at least two electrodes 411, which are used to acquire the ECG signals used by processor 20 in performing the algorithms described herein.

Apparatus 400 is controlled by processor 20 (FIG. 1), and the processor may comprise real-time noise reduction circuitry 420, typically configured as a field programmable gate array (FPGA), followed by an analog-to-digital (A/D) signal conversion integrated circuit 424. The processor can pass the signal from A/D circuit 424 to another processor and can be programmed to perform the algorithms disclosed herein.

Processor 20 is located in an operating console 430 of the apparatus. Console 430 comprises controls 432 which are used by professional 402 to communicate with the processor. During the procedure, processor 20 communicates with an ECG module 436 in a module bank 440, in order to acquire ECG signals as well as to perform the algorithms disclosed herein.

ECG module 436 receives ECG signals from electrode 411. In one embodiment the signals are transferred, in module 436, through a low noise pre-amplifier 438, and via a band pass filter 440, to a main amplifier 442. Module 436 also comprises an analog to digital converter (ADC) 444, which transfers digitized values of the ECG signals to processor 20, for implementation by the processor of the algorithms described herein. Typically, processor 20 controls the operation of pre-amplifier 438, filter 440, amplifier 442, and ADC 444.

Thus, ECG module 436 enables processor 20 to acquire and analyze EP (electrophysiological) signals received by electrode 411, including the ECG signals referred to herein. The signals are typically presented to professional 402 as voltage-time graphs, which are updated in real time, on a display screen 450.

The software for processor 20 and module bank 440 may be downloaded to the processor in electronic form, over a network, for example. Alternatively or additionally, the software may be provided on non-transitory tangible media, such as optical, magnetic, or electronic storage media.

In order to operate apparatus 12, module bank 50 typically comprises modules other than the ECG module described above, such as one or more tracking modules allowing the processor to track the distal end of probe 408. For simplicity, such other modules are not illustrated in FIG. 1. All modules may comprise hardware as well as software elements.

In addition to display screen 450 presenting ECG signals acquired by electrode 411, results 452 of the algorithms described herein may also be presented to the algorithm user on the display screen.

It will be appreciated that the embodiments described above are cited by way of example, and that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof which would occur to persons skilled in the art upon reading the foregoing description and which are not disclosed in the prior art. 

What is claimed is:
 1. A computer implemented method for annotating ECG signals with the time of activation of a myocardium, comprising: receiving a bipolar ECG signal from a location in the heart from a pair of electrodes; receiving a unipolar ECG signal from the location in the heart from a selected one electrode of the pair of electrodes; computing a local unipolar minimum derivative of the unipolar signal at a plurality of times of occurrences of the local unipolar minimum derivative; computing a bipolar derivative of the bipolar signal; evaluating a ratio of the bipolar derivative to the local unipolar minimum derivative at the plurality of times of occurrences of the local unipolar minimum derivative; annotating each time of occurrence as a time of activation of the myocardium at the location in the heart when the ratio is greater than a preset threshold value; merging two annotations that arise from a single occurrence as a single annotation; evaluating features of the annotations and assigning a confidence level to each feature; eliminating annotations that have a confidence level below a threshold; and generating a local activation time map using the remaining annotations.
 2. The method according to claim 1, further including pre-processing the bipolar ECG signal and unipolar ECG signal prior to computing the local unipolar minimum derivative of the unipolar signal and the bipolar derivative of the bipolar signal.
 3. The method according to claim 2, wherein the pre-processing includes removal of baseline wander and low pass filtering.
 4. The method according to claim 3, wherein pre-processing the unipolar ECG signal includes baseline estimation and subtraction using a median filter and a low pass filter, upsampling, first smoothing filtering using a convolution filter and second smoothing filtering using an antialiasing filter.
 5. The method according to claim 3, wherein pre-processing the bipolar ECG signal includes baseline estimation and subtraction using a median filter and a low pass filter, upsampling and smoothing filtering using a convolution filter.
 6. The method according to claim 1, further including identifying candidate time of occurrences of the plurality of times of occurrences of the local unipolar minimum derivative as candidate annotations of the time of activation of the myocardium.
 7. The method according to claim 6, further including extracting features for each of the candidate annotations.
 8. The method according to claim 7, further including eliminating at least one of the candidate annotations based on a subset of the extracted features.
 9. The method according to claim 8, further including assigning a confidence level based on a feature value for each of the candidate annotations.
 10. The method according to claim 9, further including computing the confidence level value includes computing a time duration of a downward segment of the unipolar minimum derivative, computing an amplitude of a unipolar slope segment within the time duration, computing a ratio between the amplitude and the time duration and computing an amplitude of the bipolar derivative within the time duration.
 11. An apparatus, comprising: a probe having a distal end portion and being adapted for insertion into a heart of a living subject; a pair of electrodes located along the distal end portion configured to be placed in proximity to a myocardium of a human subject; and a processor configured to perform: receiving a bipolar ECG signal from a location in the heart from the pair of electrodes; receiving a unipolar ECG signal from the location in the heart from a selected one electrode of the pair of electrodes; computing a local unipolar minimum derivative of the unipolar signal at a plurality of times of occurrences of the local unipolar minimum derivative; computing a bipolar derivative of the bipolar signal; evaluating a ratio of the bipolar derivative to the local unipolar minimum derivative at the plurality of times of occurrences of the local unipolar minimum derivative; annotating each time of occurrence as a time of activation of the myocardium at the location in the heart when the ratio is greater than a preset threshold value; merging two annotations that arise from a single occurrence as a single annotation; evaluating features of the annotations and assigning a confidence level to each feature; eliminating annotations that have a confidence level below a threshold; and generating a local activation time map using the remaining annotations.
 12. The apparatus according to claim 11, wherein the processor is further configured to perform pre-processing the bipolar ECG signal and unipolar ECG signal prior to computing the local unipolar minimum derivative of the unipolar signal and the bipolar derivative of the bipolar signal.
 13. The apparatus according to claim 12, wherein the pre-processing includes removal of baseline wander and low pass filtering.
 14. The apparatus according to claim 13, wherein pre-processing the unipolar ECG signal includes baseline estimation and subtraction using a median filter and a low pass filter, upsampling, first smoothing filtering using a convolution filter and second smoothing filtering using an antialiasing filter.
 15. The apparatus according to claim 13, wherein pre-processing the bipolar ECG signal includes baseline estimation and subtraction using a median filter and a low pass filter, upsampling and smoothing filtering using a convolution filter.
 16. The apparatus according to claim 11, wherein the processor is further configured to perform identifying candidate time of occurrences of the plurality of times of occurrences of the local unipolar minimum derivative as candidate annotations of the time of activation of the myocardium.
 17. The apparatus according to claim 16, wherein the processor is further configured to perform extracting features for each of the candidate annotations.
 18. The apparatus according to claim 17, wherein the processor is further configured to perform eliminating at least one of the candidate annotations based on a subset of the extracted features.
 19. The apparatus according to claim 18, wherein the processor is further configured to perform assigning a confidence level based on a feature value for each of the candidate annotations.
 20. The apparatus according to claim 17, wherein the processor is further configured to perform computing the confidence level value includes computing a time duration of a downward segment of the unipolar minimum derivative, computing an amplitude of a unipolar slope segment within the time duration, computing a ratio between the amplitude and the time duration and computing an amplitude of the bipolar derivative within the time duration. 